“Doing More with Less” · 24.06.2011 · the IFF and the South East (NHS) Education Forum). The second presentation from Derek Phillips, Southeast Regional Workforce Planning

Published September 2011 Page: 1

“Doing More with Less”

7th Event Report of the

SE (NHS) Education Forum

24 June 2011

Key Contacts: Commissioned in partnership through the SEAT Workforce Education & Development Advisory

Group, on behalf of the South East (NHS) Education Forum by Fiona Gailey, Educational Development

Directorate, and William Reid, NHS Education for Scotland; and also on behalf of SEAT by Derek Phillips, South

East Regional Workforce Planning Director.

Facilitated by Andrew Lyon, International Futures Forum

For further information on the work of the SEAT Workforce Education and Development Advisory Group, SE

(NHS) Education Forum – see the NES website at: http://tiny.cc/sfu1p

Doing more with less: a South East (NHS) Education Forum

Conversation, involving also other stakeholders


Friday 24th

June 2011, Scottish Health Service Centre, Edinburgh

This report

summarises the

key elements of

discussion at the

seventh event of

the South East

(NHS) Education

Forum1.

This particular

event was a

partnership

initiative between

the SE (NHS)

Education Forum

and SEAT, with a mixture of participants from the service including service and

workforce planning, education & training, organisational development and

other partners and stakeholders.

The report also outlines some key messages for the main themes of the event

conversation for participants and for other stakeholders in a position to

advance recommendations.

Priority conversation themes identified by earlier work of the SE (NHS)

Education Forum involved:

• Demography – what staff are needed to deliver the service?

• Skills, training education and learning, including working across professional boundaries

• Strategic leadership – a development need for an uncertain world

• Increasing demand for NHS services – the current system is not sustainable

• Culture and culture change – do we have the capacity to deal with the change?

1 This strategic alliance is made up of members of the SEAT Workforce Education & Development Advisory Group (chaired by David

Christie, NHS Fife), University & College provider nominees, SE NES Multiprofessional Team and other partner workforce development

expertise from the local service and national level. The SE (NHS) Education Forum is chaired by Professor Bill Reid, Postgraduate Dean, NHS

Education for Scotland.


Forum Conversation Key Messages:

In areas of challenge for the South East region of Scotland

NHS Culture and culture change, strategic leadership

• Create a space in which key leaders in the NHS, local authority and voluntary

sectors, users, carers and frontline staff can co-create, with integrity, a living

vision, relevant for times of complexity, change and uncertainty, which is

deliverable and based on a strong agreed value base.

• A perspective jointly developed by key stakeholders could help to guide policy and

action in changing, uncertain, complex circumstances.

Education and learning

• Develop staff to their potential for current and emerging service needs

• Adopt a learning, rather than a judging approach to evaluation

Working across professional boundaries

• Cross professional boundaries more often in discussion, learning, training and

action.

• Support training and development that is fit for service in changing conditions:

identify and quantify the service required and then what is needed in terms of

skills, competencies and knowledge

Demographic change

• Develop action which acknowledges “age as an asset” in the service

• Develop career structures within the service for all who work in it

Increased demand for services

• Contribute to the reorganisation of care by identifying key stakeholders and

arranging an initial meeting to share knowledge, skills and intelligence.

• Public involvement and ownership: reduce reliance on professional care and

ensure that the public are able take more responsibility by equipping the public

with the information and tools needed for a big public conversation which is

honest and open about the limits of the existing arrangements.

• Develop a framework to monitor and evaluate service changes.

Communication

• Communication needs to shift from a broadcasting based model in which

messages are developed and sent out to a model in which perspectives are jointly

developed with other key stakeholders.

• This shift should make full use of social media.


The two cartoons in this report by International Futures Forum (IFF) cartoonist

Tony Beesley also act as something of a summary: these cartoons suggest

that, in times of such change as we are currently living through, singular

solutions based on existing formats and frameworks are unlikely to be

sufficient. In order to fulfil our aspirations for care, change is necessary.


Reality is… Doing more with less to

higher quality and more safely

“Quicker, better, cheaper, safer”

How are we to develop an approach

to learning which is appropriate for

times of rapid change uncertainty and

complexity?

I used to follow, yeah that’s true, but

now my following days are over and

now I’m just going to follow through.

Advice from Lou Gramm, Midnight

Blue, via David Lee

Introduction

Professor William Reid, chair of the South East (NHS) Education Forum, welcomed participants to the

event. In doing so he suggested that the forum had developed a number of perspectives during his

time as chair, such as from the Forum’s “age as an asset” research and the previous forum

stakeholder event which had anticipated the dimension of the current economic downturn and

highlighted the importance of the forum in assisting colleagues to address difficult challenges. He

described the event today as a “safe space” in which it was permissible to express any idea or

perspective since to be as inventive as the situation requires needs us all to be open to both new

ideas and to change.

Fiona Gailey added her welcome and highlighted the

multidisciplinary nature of the group assembled. She told

us that David Lee, an active and enthusiastic founding

member of the Education Forum was retiring today and

so therefore could not be with us. Fiona took this

opportunity to both thank him and wish him well.

How our Conversation was organised

The day began with two scene setting “presentations”. These were followed by group work on

challenging themes for the south east NHS and partners. Groups paired up in the afternoon to

identify priorities and integrate the suggestions which had arisen in the morning, all within the

context of the “Doing more for less”. The programme is attached as Appendix 1.

The first presentation from Andrew Lyon of the

International Futures Forum (IFF) focussed on the nature

of the global context within which health care challenges

now need to be addressed. He re-engaged participants

with earlier Forum work; and for some attending their

first Forum event Andrew highlighted the need to “break

out of the business as usual cycle”.

Andrew Lyon suggested that the current context of change, uncertainty and complexity was the

result of our living through a change of age (rather than an age of change) in which over a period of

several decades, fundamental shifts occur in cultures which render accepted arrangements for social

and economic life to be fundamentally changed. Our key ideas and principal forms of organisation

are feeble in the face of this, which raises the question of what we are to do, the focus of today’s

conversation.

(All of the slides used in the presentation are drawn from and freely available at

http://www.internationalfuturesforum.com/projects.php?id=25 as part of a resource developed by

the IFF and the South East (NHS) Education Forum).

The second presentation from Derek Phillips, Southeast

Regional Workforce Planning Director was on overview of

“Doing more with less: Key Challenges.” He began by

outlining increases in demand and treatment alongside

projections of a reducing budget and the national quality

framework. He then asked how we might weather the


storm and lay the foundations of a more robust system for after the storm had passed.

Derek outlined six key challenges which had been previously identified by the Forum Planning Team:

• Culture and culture change

• Education and Learning

• Strategic leadership

• Working across professional boundaries

• Demography

• Increasing demand (for services)

Group Work

The morning group work session was organised around these six issues, one group for each. The

framework for the group discussion was structured along the lines of a four part story board, like

those used in film development, the components being:

• What did we set out to do/what was the initial condition for the issue under discussion?

• Where do we find ourselves now?

• What action do we therefore need to take?

• What do we hope to achieve as a result?

The main conclusions of each group are described below.

Culture and culture change

At the inception of the NHS our culture set out to provide comprehensive, patient centric care of

high quality with an appropriate balance between specialised and general functions in an integrated

manner.

We now find ourselves operating in a fragmented system where inter-professional cooperation is

poorly developed and health and social care are divided resulting in poor continuity of care for

patients. Specialisation has been over developed at the expense of generalism.

The group proposed that educational governance for the NHS be developed which reflects overall

intentions and that this should drive clinical governance and excellence. This will help to re-establish

a more helpful balance between excellence (requiring silos) and system competence (requiring co-

operations across systems). The desire should be for simplicity and order generating rules which

acknowledge complexity rather than ignore or attempt to tidy it up.

By taking such actions our intention is to develop distributed leadership in which form follows

function, metrics are meaningful and proportionate in relation to intentions. This will enable staff to

be fully engaged, resulting in better patient care.


The thing that came up in all our

conversations was integrity and

values. People want to hear about

this and will focus on it

Education and Learning

Originally the NHS set out to be what we might now call a learning organisation. Effort was made to

ensure that staff were well qualified, appropriately skilled and able to perform the roles needed to

provide a fit for purpose service in which transferable learning was both cost effective and safe.

Now we find ourselves in a situation where there is no real time to learn. Learning is not so highly

valued by the culture and so it is squeezed as the capacity of system is increasingly stretched. There

is growing evidence that education and learning for health care is in many areas not appropriate for

today’s or tomorrow’s circumstances. Team learning looks promising in this regard.

To address these challenges the group suggested that real priority be given to learning in a context

where stakeholders in care have a shared understanding of what goals are and what service

direction is being followed to achieve these goals. This should help to avoid “knee jerk reactions”,

and allow for better prioritisation and targeting of training.

The experience of older staff should be utilised as an asset in learning.

The desired results of such action the result would be a system with no fear of change.

Development would have sufficient flexibility to enable it to work effectively for patients across a

range of circumstances, some of which cannot be anticipated in advance.

Strategic Leadership

The NHS set out to provide free care for all and manage

“demand” in a fair and equitable way. The provision of

medical treatment emphasised hospital care and

infectious diseases. This was seen as a fundamental

change for the better at that time and the population

were grateful!

Now we find that the fabric of society has changed significantly since that time. Family and

community networks are eroded. Consumerism in society has raised expectations of health care and

new treatments and greater specialisation, made possible by advances in medical science, has

increased demand. Simultaneously, the population has been ageing and the burden of ill health is

shifting from acute to chronic conditions. What was once seen as the gift of free health care at the

point of need is now seen largely as a right. These developments have seen the scale of NHS

increase enormously with many more staff and a larger number of very highly paid staff working in a

risk-averse system.

The group proposed three actions:

• Develop forms of care which engage community more fully and strike a more sustainable

balance between the right to care and the responsibility for self care in a patient centred

system.

• Greater partnership working, inside and outside of hospital settings energised by a

compelling vision of purpose and what integration and high quality relationships might make

possible.

• Better sharing of information so that informed choices can be made at each and every level

of organisation.


We need honest clarity, about the

realities of the situation which we

actually face

Can we have a multiprofessional

conversation about health and social

care which begins to address this

fragmentation?

The group suggested that these actions would help to develop a clear shared vision of purpose

focussed on service. This would help to develop a patient centred system focussed on outcomes

rather than a bureaucracy driven system. The qualities which would drive such a system would be

quality of patient outcome, learning, value for money (VFM) and fitness of purpose.

Working across Professional Boundaries

The NHS set out to provide appropriate treatment free at

the point of need to all. This had been accompanied by

specialisation as a key method which the post war system

had at its disposal. This method has been largely

maintained to the present time and so we now find

ourselves in a system with a significantly increased number of professional groups across a range of

organisations in the public sector trying to provide care in circumstances largely different from those

for which the system had originally been devised.

These changed circumstances contribute to stress in the organisation and this has the effect of

evoking a response to deal with each stressor as it appears, which in turn increase stress in the

system creating a vicious circle of stress and response. Accountability is a desirable in any system

providing care, however in a system characterised by fragmentation, professional responsibility can

result in responsibility being passed around for no desirable outcome.

The group suggested two actions to address these challenges:

• Firstly, attention should be focussed on managing learning rather than managing change.

Part of this shift should be learning skills for working across professional boundaries in the

interest of patient outcomes.

• Secondly, staff are treated as mature and responsible participants whose contribution is

appreciated so that the resulting culture of care becomes the key driver of improved patient

outcomes rather than simply targets.

Demography

This group said that the NHS set out to have the right people

in the right place at the right time to deliver its service. This

needed a sustainable workforce skilled to the appropriate

level. The system remains target /policy driven which tends to

result in it being focussed on delivering more of the same.

Now we find ourselves in a situation where 30% of staff are over the age of 50. This average hides

hot spots where the proportion is much higher. When the possibility of early retirement is factored

in it becomes increasingly difficult to accurately anticipate workforce structure and experience. The

possibility is that significant experience will be lost to the service over the next few years.

The population at large is also ageing. This combined with increasing expectations of the service in

general suggests that we do not know whether the older workforce will be fit to care for older

patient cohorts.


“We set out to scale a mountain

when we didn’t know what was

above the clouds”

Let’s learn from where things are

going well

The complexity of the situation creates a lack of understanding of what might be required for a

coherent and effective NHS. This complexity creates easy targets for cuts to service from which there

may be unintended or unexpected consequences and is compounded by the fragmentation of social

and health care services.

The ability of the NHS to attract young people in sufficient numbers is not helped by an over

emphasis on qualifications and an under emphasis on caring as a vocation.

The group suggested five actions to address the above:

• An increase in apprenticeships rather than academic only routes into caring

• A greater focus on succession planning

• Workforce redesign based on better understanding of the sill mix required for desired

outcomes

• Lesser emphasis on over prescriptive targets

• System redesign to reflect an ageing workforce

The desired outcome is: a more robust system which has the right people with the right skills in the

right place at the right time; reflecting the needs of an ageing workforce providing a more holistic

service in a changing environment.

Increasing demand

The group suggested that the NHS has set out to create

equality, resolve health inequalities and fulfil public

expectations by creating a fair system in which people are

prepared to wait their turn.

The group suggested that we now found ourselves stuck with increasing demands, the victims of our

own success in an unsustainable situation. This represents a crossroads for the NHS. Where the

choices are among...

• Continue to expand in all directions and hope subsequent generations will clear up the mess

• Shrink back to an affordable level of core services

• Split the service up further and try to maintain links

• Scrap the system completely and begin again……

And noting, the risks and opportunities attached to each.

The single action which the group suggested as a matter

of urgency to address these challenges is the undertaking

of a large honest public debate about the fundamental

priorities of future possible services to set the principles

for what comes next.

• The outcome which the group sought from this was the framing of a set of principles which

re-emphasised fairness alongside individual responsibility and honesty that the system

would not be able to meet all of the demands of all of the people.

We need ways develop a BIG

conversation with the public we are

not good at communicating with

people who don’t come to us


How do we help people develop to

their full potential?

We have a genius for taking a good

idea too far, for example governance

or personal development become

bureaucratised and we lose the

original intention

We need a simple way – simple one

liners, cartoons – to highlight why we

just can’t stay the same

Afternoon Session

Following the lunch break, three groups were formed by joining the morning themes together:

• demographics and education;

• culture and leadership;

• increased demand and working across boundaries.

The key task for the groups was to identify the key issues which had been raised in the morning

session, to group these into categories, name these categories and construct a key action statement

for each category.

Forum Group Conversations: Prioritised Action Statements:

Education and Demographics

• Develop action which acknowledges “ age as asset “

in the service

• Develop staff to their potential, beginning with

training for current roles and moving into anticipatory training and development

• Undertake a service needs analysis

• Deconstruct current silos

• Develop career structures within the service for all who work in it

Culture, Culture change and Leadership

The group devised three related statements.

• Firstly, the group suggested that people readily

recognise integrity and a strong value base. These

features should therefore be embedded in the

nature of leadership and form the basis for a joint

conversation on what to do next.

• The group proposed the creation of a space in

which key leaders in the NHS, local authority and

voluntary sectors, users, carers and frontline staff can co-create, with integrity, a living vision

which is deliverable, based on a strong agreed value base.

• Secondly, the group suggested that such a vision could

operate like a satellite navigation system. A vision

jointly developed by key stakeholders could help to


We tend to over dramatise moral

choice. What is the moral framework

which ensures that people are treated

well everyday as a matter of course

We are digging the trenches deeper

We need to balance separation and

integration of services more

appropriately

guide policy and action in changing, uncertain, complex circumstances.

• Thirdly, the group suggested that tolerance for

uncertainty and complexity would be helpful in getting

beyond simplistic formulations of blame and credit in

the system. The group proposed the development of

clarity of understanding about the realities of the

situation in which we find ourselves and communicating

this to all.

Increased Demand and Working across boundaries

This group submitted four action statements.

• Training and development that is fit for service: Identify

and quantify the service required and then what is

needed in terms of skills, competencies and knowledge.

• Reorganisation of care: Identify key stakeholders and arrange an initial meeting to share

knowledge, skills and intelligence.

• Public involvement and ownership: reduce reliance on

professional care and ensure that the public take more

responsibility by equipping the public with the

information and tools needed for a BIG public

conversation.

• Optimising Value: Develop a framework to monitor and evaluate service changes.

Concluding Remarks

In drawing the event to a close Professor William Reid thanked participants for their contributions

to the forum conversation. He suggested that there were an insufficient number of opportunities

for health care, social care and education professionals to get together to discuss fundamental

questions of purpose, direction, partnership and joint challenge. Discussions and actions which

we might enter into voluntarily to address the central challenges which we all face in changing

times are rare. The South East (NHS) Education Forum gives an opportunity to do just that and to

follow through if we so desire.


PROGRAMME

Doing more with less: a South East (NHS) Education

Forum Conversation

Friday 24th

June 2011

09.30 – 15.30

Scottish Health Service Centre, Crewe Road South,

Edinburgh EH4 2LF

Purpose

To highlight key issues which need to be addressed in relation to NHS education and learning – especially

during a recession?

Enable participants to outline key concerns around these and to begin the process of identifying and taking

appropriate partnership action

To provide a coherent and, hopeful and realistic, relevant, useful conversation for a recession, in a global

context

9.30 Registration, Coffee and networking – doing more with less

10.00 Welcome to the Forum Professor Bill Reid, NES, Chair

10.10 Beyond squeezing the Balloon,

What are the implications of rapid change, complexity uncertainty and recession for NHS staff training

retention and development, Andrew Lyon, IFF

Appendix 1


10.30 Key challenges likely to be forgotten in an economic downturn

Derek Phillips, SEAT

10.50 Buzz groups - instant reactions, leading into plenary

11.15 Coffee and more networking – How can you enable doing more with less?

11:35 Priority themed discussions

12.35 Conversations through Story Boards

13.00 Lunch

13.45 Group work - What then has to be done?

14.30 One Point Feedback – First steps

14.50 Next steps – Doing more or less? Led by Andrew Lyon

15.20 Close – Bill Reid

15.30 ends

facilitated by: Andrew Lyon, International Futures Forum

SEAT Workforce Education and Development Advisory Group -

(Fiona Gailey, Derek Phillips, David Christie, Janet Corcoran, Karen Howe, William Reid)

© NHS Education for Scotland 2011. You can copy or reproduce the information in this document for use within NHSScotland and for non-commercial educational purposes. Use of this document for commercial purposes is permitted only with the written permission of NES. NHS Education for Scotland, 5th Floor, Thistle House, 91 Haymarket Terrace, EDINBURGH, EH12 5HD

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“Doing More with Less” · 24.06.2011 · the IFF and the South East (NHS) Education Forum). The second presentation from Derek Phillips, Southeast Regional Workforce Planning